Robot-assisted gait training in individuals with spinal cord injury: A systematic review for the clinical effectiveness of Lokomat

BackgroundSpinal cord injury (SCI) is a critical medical condition that causes numerous impairments leading to accompanying disability. Robotic-assisted gait training (RAGT) offers many advantages, including the capability to increase the intensity and total duration of training while maintaining a physiological gait pattern. The effects of the RAGT ‘Lokomat’ on various impairments following SCI remain unclear.ObjectivesThis review was conducted to examine the impacts of the RAGT ‘Lokomat’ on the impairments following SCI.MethodsWe searched PubMed, SCOPUS, PEDro, REHABDATA, MEDLINE, EMBASE, and web of science from inception to January 2021. Experimental studies examining the effects of the Lokomat on the impairments following incomplete SCI were selected. The methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.ResultsSixteen studies were met the inclusion criteria. Thirteen were randomized controlled trials, two were clinical trials, and one was a pilot study. The scores on the PEDro scale ranged from two to eight, with a median score of six. The results showed evidence for the beneficial effects of the Lokomat on many motor impairments following incomplete SCI.ConclusionsThe Lokomat may improve gait speed, walking distance, strength, range of motion, and mobility after incomplete SCI. There is insufficient evidence for the effect of the Lokomat on balance, depression, cardiorespiratory fitness, and quality of life. The effects of the Lokomat on the lower extremity spasticity were limited.     

Virtual reality training to enhance behavior and cognitive function among children with attention-deficit/hyperactivity disorder: brief report

ABSTRACT

Purpose: To examine the feasibility and efficacy of a combined motor-cognitive training using virtual reality to enhance behavior, cognitive function and dual-tasking in children with Attention-Deficit/Hyperactivity Disorder (ADHD).

Methods: Fourteen non-medicated school-aged children with ADHD, received 18 training sessions during 6 weeks. Training included walking on a treadmill while negotiating virtual obstacles. Behavioral symptoms, cognition and gait were tested before and after the training and at 6-weeks follow-up.

Results: Based on parental report, there was a significant improvement in children’s social problems and psychosomatic behavior after the training. Executive function and memory were improved post-training while attention was unchanged. Gait regularity significantly increased during dual-task walking. Long-term training effects were maintained in memory and executive function.

Conclusion: Treadmill-training augmented with virtual-reality is feasible and may be an effective treatment to enhance behavior, cognitive function and dual-tasking in children with ADHD.     

Robot-assisted gait training using a very small-sized Hybrid Assistive Limb® for pediatric cerebral palsy: A case report

PurposeGait parameters and gross motor function improve after 12 sessions of small-sized Hybrid Assistive Limb® (S-HAL) training in adult cerebral palsy (CP) patients. However, there are no reports on repetitive robot-assisted gait training using the newly developed very small-sized HAL (2S-HAL). This study aimed to examine the effect of using 2S-HAL on a pediatric CP patient.MethodsThe subject was an 11-year-old boy (height = 138 cm, weight = 30 kg) with spastic quadriplegia due to periventricular leukomalacia, with Gross Motor Function Classification System level IV. HAL training was performed for 2–4 sessions/week for 20 min/session (i.e., 4-week period with 12 sessions). Outcome measures were walking ability, gross motor function, Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, after, and at 1, 2, and 3 months after HAL-assisted gait training.ResultsAfter HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), Gross Motor Function Measure (GMFM), and COPM increased and physiological cost index (PCI) declined compared to those before intervention.The peaks of gait speed, step length, and cadence were 2 month, 1 month, and 3 month, respectively. 6MD, PCI, and GMFM at 1–3 months post-intervention were maintained. COPM peaked at 1 month post-intervention but remained higher than that before intervention.ConclusionThis is the first report of repetitive intervention using 2S-HAL in a pediatric CP patient. Gait training using 2S-HAL may be effective in CP patients as it improves post-training walking ability and gross motor function.     

Musculation à haute intensité et paralysie cérébrale : utopie ou révolution ?

AimOur study aimed at testing whether high intensity strength training protocols (20 minutes duration, twice a week, without exercise machine) improve functional independence and quality of life in cerebral palsy patients.MethodEighteen children (eleven boys, seven girls, aged eight to twenty years old) suffering from cerebral palsy and receiving physical therapy interventions. The experimental group received 20 minutes of high intensity strength training twice a week (during the physical therapy session) for three months. The control group receives classical physical therapy intervention. Before and after the protocol, two test sessions measured: muscle force and muscle endurance (maximum number of repetitions in 30 s, four exercises; maintain isometric positions for a maximal duration, four positions), walking speed (six minutes walking test), functional motor abilities (EMFG scale item D and E) and quality of life (Kidscreen 27 scale).ResultsThe group receiving high intensity strength training significantly improved his performance (force, endurance and function) compared to the control group. A similar trend was observed for the quality of life although differences did not reach significance.ConclusionThis study shows that patients suffering from cerebral palsy can benefit from short high intensity strength training protocols. Twenty minutes of such an intervention, twice a week, without any exercise machine, seems to be an effective and realistic strategy to improve force, endurance, motor function and quality of life.     

Robot-assisted gait training might be beneficial for more severely affected children with cerebral palsy

Purpose: Robot-assisted gait training (RAGT) can complement conventional therapies in children with cerebral palsy. We investigated changes in walking-related outcomes between children with different Gross Motor Function Classification System (GMFCS) levels and the dose–response relationship. Methods: Data from 67 children (3.9–19.9 years) with GMFCS levels II–IV were evaluated retrospectively. Every child received RAGT with the Lokomat complementing a multidisciplinary rehabilitation program. Changes in various walking-related outcomes were assessed. Results: Walking-related outcomes did not improve differently between GMFCS level groups. Significant within-group improvements were mainly observed in children with GMFCS level IV. A dose–response relationship was present for children with GMFCS levels III and IV. Conclusions: Our results indicated that, although children with a GMFCS level IV walked less during an average Lokomat session, they experienced significant improvements in walking-related outcomes. Further, training dose correlated with changes in walking-related outcomes. However, between-group differences in changes in walking-related outcomes were not significant.     

Safety and immediate effects of Hybrid Assistive Limb in children with cerebral palsy: A pilot study

PurposeEarly intervention is effective for developing motor ability and preventing contractures and deformities in patients with cerebral palsy (CP). Gait training using the newly developed Hybrid Assistive Limb (HAL) shows promise as an intervention to prevent deterioration in walking ability and deformities in pediatric CP patients. The purpose of this pilot study was to examine the safety and immediate effects on walking ability after gait training using the HAL in pediatric CP patients.MethodsNineteen patients (six females, 13 males; mean age 8.5 years; mean height 120.5 cm; mean weight 23.2 kg) were enrolled. The Gross Motor Functional Classification Scale level was I in two patients, II in two, III in eight, and IV in seven. The HAL was used for a single session of gait training. The primary outcome was safety of the HAL for use in pediatric CP patients. The secondary outcome was the immediate effect after gait training with HAL, evaluated by passive range of motion (ROM) and gait parameters, including gait speed (m/s), step length (cm), and cadence (step/min).ResultsAll 19 patients were able to carry out the gait training without any severe adverse events. Significant improvements were observed for mean internal/external rotation and abduction angles of the hip joint, and ankle dorsiflexion angles (n = 19). Significant improvements were observed for mean gait speed and step length based on expansion of the hip flexion-extension range (n = 11).ConclusionGait training using the HAL is safe and can produce immediate improvements in ROM and walking ability in pediatric patients with CP.     

Interlimb coordination during forward walking is largely preserved in backward walking in children with cerebral palsy

ObjectiveLimb kinematics in backward walking (BW) are essentially those of forward walking (FW) in reverse. It has been argued that subcortical mechanisms could underlie both walking modes.MethodsTherefore, we tested whether participants with supraspinal/cortical deficits (i.e. cerebral palsy) show the kinematic reversal from FW to BW. 3D gait analysis was performed in 15 children with diplegia and 11 children with hemiplegia to record elevation angles of upper arm, lower arm, upper leg, lower leg, and foot, and were compared to those of 23 control subjects. Coordination patterns were compared between FW and BW, and elevation angle traces of BW were reversed in time (revBW) and correlated to FW traces.ResultsThe interlimb coordination pattern during BW was largely preserved for all groups. The kinematic reversal of the limbs was also present in children with cerebral palsy (represented by high correlation coefficients between FW and revBW kinematics).ConclusionsThe neural control mechanism of FW leading to BW, is preserved in persons with cortical deficits (as in cerebral palsy).SignificanceThe current results support previous evidence suggesting that interlimb locomotor coordination depends mostly on the coupling between spinal pattern generators, coordinated by brainstem mechanisms, rather than primarily on cortical structures.     

The use of botulinum toxin type A treatment in children with spasticity

The current modalities in managing spastic children have some limitations; thus, alternative therapeutic agents are in need. The purpose of this study is to investigate whether intramuscular botulinum toxin type A administration may be an alternative agent in the treatment of children with cerebral palsy. Eighteen children who were aged between 3 and 17 years and manifested cerebral palsy were administered intramuscular botulinum toxin type A with a total dose of 6 U/kg body weight. Outcome measurements were determined with four methods, including Ashworth Spasticity Scale, standardized videotape assessments, observational gait analysis, and walking velocity. Ashworth Spasticity Scale and videotape assessments were statistically significant before and after treatment in all muscles (P < 0.001). The best improvement in video gait analysis was evident at week 8. The botulinum toxin type A injections yielded an improved walking velocity at all visits. The observational gait analysis and walking velocity demonstrated an improvement after treatment in the gastrocnemius-injected group (P < 0.001). In conclusion, intramuscular botulinum toxin type A administration may be effective in children with cerebral palsy, especially at week 4 and when injected in gastrocnemius.     

Virtual realities as motivational tools for robotic assisted gait training in children: A surface electromyography study

Patient's active cooperation is essential to achieve good outcome in pediatric rehabilitation. Therefore, virtual environments were developed to enhance robotic assisted gait training. The purpose of this study was to evaluate virtual realities as motivational tools during robotic assisted gait training with children in the pediatric Lokomat?. Nine children with different gait disorders and eight healthy children participated in the study. Muscular effort of the lower leg was assessed by surface electromyography during a randomly designed training protocol with virtual realities. Self reported motivation was investigated with two questionnaires. Comparisons were drawn through repeated measurement Analysis of Variance and paired-t-tests. The logarithmic transformed data showed that the electromyographic activity output in both groups was significantly higher during tasks with virtual realities than during normal walking conditions. These results support that virtual realities seem to be efficient motivational tools to increase children's muscular effort in the pediatric Lokomat?. The gaming aspect of virtual realities keeps children highly engaged during repetitive tasks.     

Gait Improvement in Patients with Cerebral Palsy by Visual and Auditory Feedback

Objectives: To study the effects of gait training with visual and auditory feedback cues on the walking abilities of patients with gait disorders due to cerebral palsy. Materials and Methods: Visual and auditory feedback cues were generated by a wearable device, driven by inertial sensors. Ten randomly selected patients with gait disorders due to cerebral palsy and seven age‐matched healthy individuals trained with visual feedback cues, while ten patients and eight age‐matched healthy individuals trained with auditory feedback cues. Baseline performance (walking speed and stride length along a 10‐m straight track) was measured before device use. Following 20‐min training with the device and a 20‐min break, performance without the device was measured again and compared with the baseline performance. Results: For the patients who trained with visual feedback, the average improvement was 21.70% ± 36.06% in the walking speed and 8.72% ± 9.47% in the stride length. For the patients who trained with auditory feedback, the average improvement was 25.43% ± 28.65% in the walking speed and 13.58% ± 13.10% in the stride length. For the healthy individuals who trained with visual feedback, the average improvement was ?2.41% ± 9.54% in the walking speed and ?2.84% ± 10.11% in the stride length. For the healthy individuals who trained with auditory feedback, the average improvement was 0.01% ± 7.73% in the walking speed and ?2.03% ± 6.15% in the stride length. Conclusions: Training with visual and auditory feedback cues can improve gait parameters in patients with gait disorders due to cerebral palsy. This was contrasted by no improvement in age‐matched healthy individuals.     

Empleo de sistemas de realidad virtual como método de propiocepción en parálisis cerebral: guía de práctica clínica

IntroductionThe limitations in performing functional activities in children and adolescents with cerebral palsy are important. The use of virtual reality systems is a new treatment approach that reinforces task-oriented motor learning. The purpose of this guide is to study the impact of the use of virtual reality systems in the improvement and acquisition of functional skills, and to evaluate the scientific evidence to determine the strength of recommendation of such interventions.DevelopmentAll available full-text articles, regardless of their methodology, were included. The following data bases were consulted: PubMed (Medline), PEDro, EMBASE (OVID-Elsevier), Cochrane Library, Medline (OVID), CINAHL, ISI Web Knowledge. An assessment was made of methodological quality, the level of scientific evidence, and the strength of recommendations using the tools: Critical Review Form - Quantitative Studies and the Guidelines for Critical Review Form - Quantitative Studies and U.S. Preventive Services Task Force. Finally, we included 13 articles and 97 participants were recruited. We obtained significant improvements in outcome measures that assessed postural control and balance, upper limb function, the selective joint control, and gait.ConclusionsThe guide has some limitations: the limited number of patients enrolled, clinical diversity and age range, as well as the methodological quality of existing trials. Virtual reality is a promising tool in the treatment of children with cerebral palsy. There is strong scientific evidence of an acceptable recommendation for the use of virtual reality systems in the treatment of cerebral palsy.     

Meta-analysis of the effect of strengthening interventions in individuals with cerebral palsy

This study aimed to investigate the evidence that strengthening interventions can improve muscle strength and activity in individuals with cerebral palsy. The search focused on studies that employed strength training for children with cerebral palsy for which six electronic databases were used to extract literature published from 2001 to 2012. The key terms used in these searches were combined strength training, strengthening, weight training, weight lifting, resistance, and cerebral palsy. The quality of each study was assessed using the PEDro (Physiotherapy Evidence Database) scale. Thirteen randomized controlled trial studies were selected and divided into categories according to program type, mode, and outcome measures. The overall effect sizes of each study and types of strengthening were large. Strengthening exercise improved muscle strength to a greater degree, when practiced 3 times per week in 40–50 min sessions than in other categories of session length, and greater improvement was observed in younger children than in older. The effect size of the activities and variables related to gait, except for gait endurance, were medium to large. The effect size of individual muscles was large, but the effect sizes for ankle plantar flexor, hip abductor/adductor, and extensor were insignificant. Strengthening interventions are useful for increasing muscle strength in individuals with cerebral palsy, specifically in youth and children, and optimal exercise consisted of 40- to 50-min sessions performed 3 times per week. Although strengthening interventions may improve activities, including gait, more studies that are rigorous are needed to determine the contributions to gross motor function.     

Increases in muscle volume after plantarflexor strength training in children with spastic cerebral palsy

Children with spastic cerebral palsy (CP) have small, weak muscles. However, change in muscle size due to resistance training in this group is unknown. We investigated the effect of plantarflexor strengthening on muscle volume, gait, and function in 13 ambulant children with spastic CP (seven males, six females; mean age 10y 11mo, SD 3y 0mo, range 6y 11mo–16y 11mo; eight with diplegia, five with hemiplegia; Gross Motor Function Classification System level I, six; level II, five; level III, two). Assessments were performed before training, 5 and 10 weeks into training, and at a 3-month follow-up. Medial and lateral gastrocnemius volumes were computed from three-dimensional ultrasound images. The number of unilateral heel raises able to be achieved on each side was assessed. Function was measured using three-dimensional gait analysis, the 'timed up and go' test, the Gillette Functional Assessment Questionnaire, and the Functional Mobility Scale. Training involved heel raises or Thera-Band resistance, 4 times a week for 10 weeks. Medial and lateral gastrocnemius volumes increased by 17 and 14% at week 5 ( p =0.03, p =0.028). This increase was maintained at week 10 and follow-up (medial gastrocnemius p =0.001, p <0.001; lateral gastrocnemius p =0.006, p =0.007). Heel raises (mean number) increased by week 5 ( p =0.002). This was maintained at week 10 and follow-up ( p <0.001; p <0.001). No significant change in measured function was observed. Muscle volume increased in response to training in children with spastic CP. The role of progressive strength training in maintaining long-term function is discussed.     

Gait analysis of children with spastic hemiplegic cerebral palsy

An experiment was carried out in the key laboratory for Technique Diagnosis and Function Assessment of Winter Sports of China to investigate the differences in gait characteristics between healthy children and children with spastic hemiplegic cerebral palsy.With permission of their parents,200 healthy children aged 3 to 6 years in the kindergarten of Northeastern University were enrolled in this experiment.Twenty children aged 3 to 6 years with spastic hemiplegic cerebral palsy from Shengjing Hospital,China were also enrolled in this experiment.Standard data were collected by simultaneously recording gait information from two digital cameras.DVracker was used to analyze the standard data.The children with hemiplegic cerebral palsy had a longer gait cycle,slower walking speed,and longer support phase than did the healthy children.The support phase was longer than the swing phase in the children with hemiplegic cerebral palsy.There were significant differences in the angles of the hip,knee,and ankle joint between children with cerebral palsy and healthy children at the moment of touching the ground and buffering,and during pedal extension.Children with hemiplegic cerebral palsy had poor motor coordination during walking,which basically resulted in a short stride,high stride frequency to maintain speed,more obvious swing,and poor stability.     

Stability and harmony of gait in children with cerebral palsy

The aim of this study was to quantitatively assess the stability and harmony of gait in children with cerebral palsy. Seventeen children with spastic hemiplegia due to cerebral palsy (5.0 ± 2.3 years old) who were able to walk autonomously and seventeen age-matched children with typical development (5.7 ± 2.5 years old, p = 0.391) performed a 10-m walking test with a wearable device fixed to their lower trunk and included a triaxial accelerometer and three gyroscopes.Three parameters related to gait stability and three related to gait harmony were computed; all of these yielded significant differences between children with cerebral palsy and those with typical development (p < 0.020 for all the computed parameters). In the latter group of children, trunk accelerations were found to be negatively correlated with age (partial correlation controlled for walking speed: R_p < −0.58, p > 0.020). Conversely, in children with cerebral palsy, the upper body accelerations were proportionally correlated with their gait speed (R = 0.548, p = 0.023 in the antero-posterior direction) but not with their age (p > 0.05). This finding can be related both to difficulties in managing the higher upper body accelerations involved in rapid walking and to compensation strategies.     

Walking-induced muscle fatigue impairs postural control in adolescents with unilateral spastic cerebral palsy

BackgroundFatigue is likely to be an important limiting factor in adolescents with spastic cerebral palsy (CP).AimsTo determine the effects of walking-induced fatigue on postural control adjustments in adolescents with unilateral CP and their typically developing (TD) peers.MethodsTen adolescents with CP (14.2 ± 1.7 yr) and 10 age-, weight- and height-matched TD adolescents (14.1 ± 1.9 yr) walked for 15 min on a treadmill at their preferred walking speed. Before and after this task, voluntary strength capacity of knee extensors (MVC) and postural control were evaluated in 3 conditions: eyes open (EO), eyes closed (EC) and with dual cognitive task (EODT).ResultsAfter walking, MVC decreased significantly in CP (−11%, P < 0.05) but not in TD. The CoP area was only significantly increased in CP (90%, 34% and 60% for EO, EC and EODT conditions, respectively). The CoP length was significantly increased in the EO condition in CP and TD (20% and 21%) and was significantly increased in the EODT condition by 18% in CP only.ConclusionsUnlike TD adolescents, treadmill walking for 15 min at their preferred speed lead to significant knee extensor strength losses and impairments in postural control in adolescents with unilateral spastic CP.     

Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial

This matched-pairs, clinical controlled trial evaluated the effects of a school-based, partial body-weight-supported treadmill training (PBWSTT) programme, conducted twice a week for 6 weeks, on the walking speed and endurance of children with cerebral palsy (CP). Pairs of children (10 males, four females; mean age 8 y 10 mo [SD 2 y 6 mo], range 5-14 y) matched for sex, age, type of CP (athetoid quadriplegia, n=6; spastic quadriplegia, n=6; spastic diplegia, n=2), and Gross Motor Function Classification System level (10 at Level I V, four at Level III) were allocated to the experimental or control group. Compared with the control group, the seven treadmill-training participants increased their self-selected walking speed over 10 metres (Mann-Whitney U=9.00, z=-1.98, p=0.048; mean difference 4.21 m/min). A trend was also found for increased distance walked over ground in 10 minutes (t[12]=1.88, p=0.083; mean difference 19.81 m). A relatively short PBWSTT programme can improve the walking speed of children with CP and moderate to severe disabilities. Walking endurance might also improve in some children. Treadmill training seems to be a useful gait training option for children with C P, and it seems feasible to conduct such a programme within a school environment.     

Approche étiologique de la paralysie cérébrale à Parakou au Nord du Bénin : étude cas-temoins

BackgroundCerebral palsy is a well-recognized neurodevelopmental condition beginning in early childhood and persisting through the lifespan. The associated factors were not well known in Africa.ObjectiveWe aimed to assess the factors associated to the cerebral palsy at Parakou.MethodsIt was a case-control study included 34 children with cerebral palsy matched to 102 controls. We had collected information about pregnancy history, early conditions in their life, and data from the lifestyle of their parents. The association between cerebral palsy and those factors was estimated with odds ratio and their confidence interval by using a logistic regression model.ResultsThe mean age was 5.4 ± 3.1 years old. The main clinical features of the children with cerebral palsy were the gait disorders (91.2 %), aphasia or speech disturbance (85.3 %), motor deficit (82.3 %) and epilepsy (58.8 %). In the multivariate analysis the associated factors were: no follow up of the pregnancy (OR: 5.9 [1.4–25.0]); acute disease during the pregnancy (OR: 7.6 [1.5–38.5]), resuscitation at the birth (OR: 16.7 [3.2–100.0]), the stay at the neonatology unit (OR: 25.0 [5.0–100.0]).ConclusionThis study suggested that the cerebral palsy can be explained by the pregnancy condition and it follow up at Parakou.     

Robot-assisted gait training versus equal intensity treadmill training in patients with mild to moderate Parkinson's disease: A randomized controlled trial

BackgroundThere is a lack of evidence about the most effective strategy for training gait in mild to moderate Parkinson's disease. The aim of this study was to compare the effects of robotic gait training versus equal intensity treadmill training and conventional physiotherapy on walking ability in patients with mild to moderate Parkinson's disease.MethodsSixty patients with mild to moderate Parkinson's disease (Hoehn & Yahr stage 3) were randomly assigned into three groups. All patients received twelve, 45-min treatment sessions, three days a week, for four consecutive weeks. The Robotic Gait Training group (n = 20) underwent robot-assisted gait training. The Treadmill Training group (n = 20) performed equal intensity treadmill training without body-weight support. The Physical Therapy group (n = 20) underwent conventional gait therapy according to the proprioceptive neuromuscular facilitation concept. Patients were evaluated before, after and 3 months post-treatment. Primary outcomes were the following timed tasks: 10-m walking test, 6-min walking test.ResultsNo statistically significant difference was found on the primary outcome measures between the Robotic Gait Training group and the Treadmill Training group at the after treatment evaluation. A statistically significant improvement was found after treatment on the primary outcomes in favor of the Robotic Gait Training group and Treadmill Training group compared to the Physical Therapy group. Findings were confirmed at the 3-month follow-up evaluation.ConclusionsOur findings support the hypothesis that robotic gait training is not superior to equal intensity treadmill training for improving walking ability in patients with mild to moderate Parkinson's disease.     

Muscle strength training to improve gait function in children with cerebral palsy

The aim of the study was to investigate the influence of muscle strength training on gait outcomes in children with cerebral palsy. Sixteen children (two females, 14 males, Gross Motor Function Classification System levels I-II, mean age 12y 6mo, range 9y 4mo-15y 4mo) underwent muscle strength measurement using a handheld device, Gross Motor Function Measure (GMFM) assessment, three-dimensional gait analysis, joint range of motion assessment, and grading of spasticity before and after 8 weeks of training. All participants had a diagnosis of spastic diplegia and could walk without aids. Training consisted of exercises for lower extremity muscles with free weights, rubber bands, and body weight for resistance, three times a week. Values for muscle strength below normal were identified in all children; this was most pronounced at the ankle, followed by the hip muscles. After training, muscle strength and GMFM scores increased, velocity was unchanged, stride length increased, and cadence was reduced. There was an increase in hip extensor moment and power generated at push off. Eight weeks of muscle strength training can increase muscle strength and improve gait function.